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Intake
|
|
|
Historian Name(s):
|
Nurse
• • •
|
|
Relationship
• • •
|
Familiarity
|
|
Reliability
• • •
|
|
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Problems
|
|
|
Problem 1
|
|
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Problem
|
Quality
|
|
Onset
|
Onset Units
|
|
Frequency
• • •
|
Frequency Units
|
|
Duration
|
Duration Units
|
|
Severity-Max
|
Severity-Avg
|
|
T-Max
|
T-Avg
|
|
Pattern
|
Progression
• • •
|
|
Aggavating
|
Alleviating
|
|
Context
|
Associated
|
|
Location (Description)
|
Location
|
|
Problem 2
|
|
|
Problem
|
Quality
|
|
Onset
|
Onset Units
|
|
Frequency
• • •
|
Frequency Units
|
|
Duration
|
Duration Units
|
|
Severity-Max
|
Severity-Avg
|
|
Pattern
|
Progression
• • •
|
|
Aggavating
|
Alleviating
|
|
Context
|
Associated
|
|
Location (Description)
|
Location
|
|
Problem 3
|
|
|
Problem
|
Quality
|
|
Onset
|
Onset Units
|
|
Frequency
• • •
|
Frequency Units
|
|
Duration
|
Duration Units
|
|
Severity-Max
|
Severity-Avg
|
|
Pattern
|
Progression
• • •
|
|
Aggavating
|
Alleviating
|
|
Context
|
Associated
|
|
Location (Description)
|
Location
|
|
Problem 4
|
|
|
Problem
|
Quality
|
|
Onset
|
Onset Units
|
|
Frequency
• • •
|
Frequency Units
|
|
Duration
|
Duration Units
|
|
Severity-Max
|
Severity-Avg
|
|
Pattern
|
|
|
Aggavating
|
Alleviating
|
|
Context
|
Associated
|
|
Location (Description)
|
Location
|
|
Follow Ups
|
|
|
Follow Up 1
|
|
|
Problem
|
|
|
Meds
|
|
|
Compliance
|
Adverse Effects
|
|
Effectiveness
|
Other Problems
|
|
Follow Up 2
|
|
|
Meds
|
|
|
Problem
|
Compliance
|
|
Adverse Effects
|
Effectiveness
|
|
Other Problems
|
|
|
Follow Up 3
|
|
|
Meds
|
|
|
Problem
|
Compliance
|
|
Adverse Effects
|
Effectiveness
|
|
Other Problems
|
|
|
Follow Up 4
|
|
|
Meds
|
|
|
Problem
|
Compliance
|
|
Effectiveness
|
Adverse Effects
|
|
Other Problems
|
Progression
• • •
|
|
Review
|
|
|
Base
|
|
|
General
• • •
|
Constitutional
• • •
|
|
Ears
• • •
|
Nose
• • •
|
|
Mouth
• • •
|
Neck
• • •
|
|
Cardiovascular
• • •
|
Respiratory
• • •
|
|
Gastrointestinal
• • •
|
Derm
• • •
|
|
Extended
|
|
|
Head
• • •
|
Eyes
• • •
|
|
Female GU
• • •
|
Male GU
• • •
|
|
Endocrine
• • •
|
Neuro
• • •
|
|
Lymphatics
• • •
|
Allergy
• • •
|
|
Heme
• • •
|
|
|
RUE
• • •
|
LUE
• • •
|
|
RLE
• • •
|
LUE
• • •
|
